Introduction:Large language models have demonstrated impressive capabilities, but application to medicine remains unclear. We seek to evaluate the use of ChatGPT on the American Urological Association Self-assessment Study Program as an educational adjunct for urology trainees and practicing physicians.Methods:One hundred fifty questions from the 2022 Self-assessment Study Program exam were screened, and those containing visual assets (n=15) were removed. The remaining items were encoded as open ended or multiple choice. ChatGPT’s output was coded as correct, incorrect, or indeterminate; if indeterminate, responses were regenerated up to 2 times. Concordance, quality, and accuracy were ascertained by 3 independent researchers and reviewed by 2 physician adjudicators. A new session was started for each entry to avoid crossover learning.Results:ChatGPT was correct on 36/135 (26.7%) open-ended and 38/135 (28.2%) multiple-choice questions. Indeterminate responses were generated in 40 (29.6%) and 4 (3.0%), respectively. Of the correct responses, 24/36 (66.7%) and 36/38 (94.7%) were on initial output, 8 (22.2%) and 1 (2.6%) on second output, and 4 (11.1%) and 1 (2.6%) on final output, respectively. Although regeneration decreased indeterminate responses, proportion of correct responses did not increase. For open-ended and multiple-choice questions, ChatGPT provided consistent justifications for incorrect answers and remained concordant between correct and incorrect answers.Conclusions:ChatGPT previously demonstrated promise on medical licensing exams; however, application to the 2022 Self-assessment Study Program was not demonstrated. Performance improved with multiple-choice over open-ended questions. More importantly were the persistent justifications for incorrect responses—left unchecked, utilization of ChatGPT in medicine may facilitate medical misinformation.

Rationale: Concern for immune-related adverse events from immunotherapy and radiation therapy are well-documented; however, side effects are mostly mild to moderate. However, high-grade, potentially life-threatening adverse events are increasing. While case reports regarding immunotherapy-related bullous pemphigoid (BP) have been rising, only 1 has described BP following concomitant use of both nivolumab and radiation therapy (RT). For that patient, nivolumab was used for 10 weeks prior to RT and development of PB followed 7 weeks later. This case presents a patient who tolerated nivolumab well for 38 months prior to developing BP less than 2 weeks after completing RT. Patient concerns: We present the case of DH, a 67-year-old gentleman on nivolumab for metastatic renal cell carcinoma to the lung since May of 2017. Following progressing lung nodules, the patient had his nivolumab paused and completed a course of short-beam radiation therapy. After restarting nivolumab post-radiation, the patient presented with itchy rash and blisters on his arm, legs, and trunk. Diagnosis: DH consulted dermatology following development of rash and was diagnosed with bullous dermatosis, likely bullous pemphigoid. Bullous pemphigoid following concomitant nivolumab (OPDIVO), despite prior tolerance and no history of autoimmune disease, was confirmed by biopsy a month later. Interventions: Initial treatment was betamethasone 0.05% cream mixed 1:1 with powder to form paste applied twice daily. Given progressive symptoms and confirmatory biopsy of BP, nivolumab was held and 100 mg doxycycline and 80 mg prednisone daily was prescribed for a week, reduced to 60 mg during the second week. Outcomes: A week following discontinuation of nivolumab and beginning of doxycycline and prednisone, the blistering and rash was almost entirely resolved. Four months later, nivolumab was restarted and the patient continued low-dose tapering of prednisone until December. Since completing prednisone, the patient has shown no recurrence of bullous pemphigoid and has not developed any other immune-related adverse events to nivolumab upon rechallenge. Follow-up through October 2021 demonstrates the patient's sites of disease, both in- and out-field, have remained responsive to treatment. Lessons: Treating physicians should be aware of off-target effects of radiotherapy for oligoprogressive disease, which may include abscopal toxicities and the development of new immune-related adverse effects.

With IRB approval, we queried the electronic medical record (EMR) for patients who were counseled and offered germline testing per NCCN guidelines from 1/29/19 e 2/3/21. Patients qualified for testing due to pathologic high risk (HR), family history (FH), or both. As referral methods evolved over time, we compared three cohorts of patients referred for testing through one of three methods. Patients were offered either 1) telephone number for a genetic counselor (TN); 2) EMR referral to a genetic counselor who calls the patient (ER); 3) same-day in-office testing (IO). The proportions of patients in each cohort who received testing were compared using chi square. Time to testing for each cohort was compared using Kaplan Meier. Multivariate logistic regression and Cox regression evaluated the independent influence of referral method and reason for referral on these outcomes. All analyses used SPSSv26.RESULTS: 177 patients were offered germline testing (47 TN, 70 ER, and 60 IO.) The cohorts did not differ in age, race, PSA, or clinical stage. The percentage of patients referred for both HR and FH was lower in the TN group compared to the ER and IO groups (6% vs 21% vs 27%, respectively, p<.025). Time to testing (Fig. 1) and receipt of testing was significantly associated with the referral method. Testing was obtained in 8 (17%) of TN, 39 (56%) of ER referrals and 39 (65%) of IO (p<0.001). 47/96 (49%) of men with family history, 16/47 (34%) of those with high risk and 23/34 (68%) of those with both risk factors obtained testing (p[0.012). Multivariate analyses indicated that referral method was independently associated with receipt of test and time to test (p < .001) while reason for testing was not significant. CONCLUSIONS: In-office germline testing is the most effective and expedient method to obtain germline testing results.

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This cohort study assesses biochemical progression-free survival among patients receiving radiotherapy for the treatment of synchronous oligometastatic prostate cancer.